IAJPS 2018, 05 (05), 4040-4045 Laiq et al ISSN 2349-7750

CODEN [USA]: IAJPBB ISSN: 2349-7750

INDO AMERICAN JOURNAL OF

PHARMACEUTICAL SCIENCES
http://doi.org/10.5281/zenodo.1251154

Available online at: http://www.iajps.com Research Article

A PROSPECTIVE RESEARCH ON THE FASCIO-CUTANEOUS

FLAPS ROLE AS AN INTERVENTION OF THE COVERAGE OF
SOFT TISSUE IN (TYPE 111 – B) OPEN TIBIAL FRACTURES
Dr. Laiq, Dr. Rameez Ahmad, Dr. Sebghat Ullah
Al- Tibri Medical College, Isra University
Abstract:
Object: The determination of the fascio-cutaneous flap role as the coverage of the soft tissue in open tibial fractures of type 111 –
B as experienced by the professor of Mayo Hospital, Lahore.
Material and Methods: Sample of this prospective research was of forty-one patients having tibia fractures of (type 111 – B).
Every case was treated in the orthopedic surgery and traumatology department from September 2015 to September 2017. We did
not include the patients diagnosed with peripheral vascular disease and diabetes mellitus. After antibiotic cover and
resuscitation debridement was carried out followed by the application of back slab. Next day of the treatment again debridement
was carried out and stabilization was also carried out with the help of external fixator. Wound became clean by numerous
debridement’s, it was now ready for flap subsequently covered with the fascio-cutaneous flap. After five days the dressing was
replaced and at the interval of two weeks removal of stitching was carried out. The basic data of the patients was assessed
regarding injury site, fascio-cutaneous flap type, complications and acceptance.
Results: The average age of the patients was observed as (31.8 years), as per the injury site 7 cases (16.66%) of proximal tibia
were sustained, 12 cases of middle tibia (28.57%), 17 cases of distal tibia (40.47%), 4 cases of middle 2/3rd (9.52%) and 2 cases
of distal 2/3rd (4.76%) tibia. Executed flaps pattern were based on the proximal medial flaps in 4 cases (9.52%), 3 cases were of
proximal based lateral (7.14%), 8 cases were of distal based medial (19%), 17 cases of distal based lateral (40.47%), 2 cases of
cross leg (4.76%), 2 cases of sural flap (4.76%), 4 cases of distal lateral retrograde (9.52%), 2 cases of random pattern flaps
(4.76%) and 2 cases of soleus muscle flaps (4.76%). In the total of 42 cases 33 cases were good (78.57%), 6 cases were fair
(14.28%) and 3 cases were poor (7.14%). Observed complications were as 6 cases of marginal necrosis (14.28%), 3 cases of
complete or partial necrosis (7.14%), 3 cases of superficial infection (14.28%) and 5 cases of deep infection (11.9%).
Conclusion: Our research concludes that fascio-cutaneous flap is a procedure which is safe, simple and cost effective along with
(type 111 – B) good acceptance of the open tibial fractures.
Key Words: Type (111 – B) open tibial fractures, fascio-cutaneous flaps and soft tissue coverage.
Corresponding author:
Dr. Laiq, QR code
Al- Tibri Medical College,
Isra University

Please cite this article in press Laiq et al., A Prospective Research on the Fascio-Cutaneous Flaps Role as an
Intervention of the Coverage of Soft Tissue in (Type 111 – B) Open Tibial Fractures, Indo Am. J. P. Sci, 2018;
05(05).

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 IAJPS 2018, 05 (05), 4040-4045
INTRODUCTION:
The management and treatment of (type 111 – B)
open tibial fractures has become a challenge for the
trauma surgeons [1]. The primary objective of the
treatment is infection prevention along with union of
the bone and function restoring. But loss of tissues at
the initial stage, fracture stability and wound
contamination largely affect treatment outcomes [2].
A good bone vascularity and healthy envelop of the
soft tissue are vital for the fracture management [3].
It may require before final coverage a serial
debridement [4]. We can convert open wound into
close through coverage of the soft tissue which also
promotes revascularization of the bone and soft
tissues which are damaged or fractured through fresh
blood which helps in the prevention of the non-union
and infection [5, 6].
Many reconstructive interventions are available for
the better management of the (type 111 – B) tibial
fractures such as direct closure, skin grafting, tissue
expansion, muscle flap, fascio-cutaneous flap, free
flaps and my-coetaneous flap [7]. Various cases are
managed specific technique which suits the
judgement of the surgeon [8]. Exposed bone cannot
be covered through split thickness skin grafting,
nerves, vessels and tendon. Because of the bulky and
large muscle flaps cosmetic and functional deficit is
provided at the site of the donor [9]. High reliability
is associated to the free flaps which requires
microvascular intervention which is extremely
technical and required expertise, cost effective,
expensive instruments, big institutions and prolonged
operating time [10].
Fascio-cutaneous flaps has become very popular in
the recent days because of its versatility, reliability
and simplicity. The selection of the flaps is made on
the basis of the location, defect depth, local covering
tissues availability and size [11]. The determination
of the fascio-cutaneous flap role as the coverage of
the soft tissue in open tibial fractures of type 111 – B
as experienced by the professor of Mayo Hospital,
Lahore.
MATERIAL AND METHODS:
Sample of this prospective research was of forty-one
patients having tibia fractures of type 111 – B. Every
case was treated in the orthopedic surgery and
traumatology department from September 2015 to
September 2017. We did not include the patients
diagnosed with peripheral vascular disease and
www.iajps.com
Laiq et al ISSN 2349-7750
diabetes mellitus. After antibiotic cover and
resuscitation debridement was carried out followed
by the application of back slab. Next day of the
treatment again debridement was carried out and
stabilization was also carried out with the help of
external fixator. Wound became clean by numerous
debridement’s, it was now ready for flap
subsequently covered with the fascio-cutaneous flap.
After five days the dressing was replaced and at the
interval of two weeks removal of stitching was
carried out. The basic data of the patients was
assessed regarding injury site, fascio-cutaneous flap
type, complications and acceptance. A total of 41
cases with 42 legs were made a part of the research
paper. After patient’s resuscitation initial care was
carried out by the analgesic, broad spectrum
antibiotics, tetanus prophylaxis and aggressive
debridement with the help of normal saline, pyodine
scrub, back slab and sterilized dressing. At the end of
the regular treatment an extensive debridement and
assessment of the wound was also carried out along
with external fixator and stabilization of the fracture.
SPSS – 16 was used for the data entry and analysis.
RESULTS:
The average age of the patients was observed as (31.8
years), as per the injury site 7 cases (16.66%) of
proximal tibia were sustained, 12 cases of middle
tibia (28.57%), 17 cases of distal tibia (40.47%), 4
cases of middle 2/3rd (9.52%) and 2 cases of distal
2/3rd (4.76%) tibia. Executed flaps pattern were based
on the proximal medial flaps in 4 cases (9.52%), 3
cases were of proximal based lateral (7.14%), 8 cases
were of distal based medial (19%), 17 cases of distal
based lateral (40.47%), 2 cases of cross leg (4.76%),
2 cases of sural flap (4.76%), 4 cases of distal lateral
retrograde (9.52%), 2 cases of random pattern flaps
(4.76%) and 2 cases of soleus muscle flaps (4.76%).
In the total of 42 cases 33 cases were good (78.57%),
6 cases were fair (14.28%) and 3 cases were poor
(7.14%). Observed complications were as 6 cases of
marginal necrosis (14.28%), 3 cases of complete or
partial necrosis (7.14%), 3 cases of superficial
infection (14.28%) and 5 cases of deep infection
(11.9%). The outcomes as shown in Table I, II and III
reflect detailed factual information about the forty-
one cases respectively about the patient’s
demographic characteristics, fixator type and flaps
pattern which was carried out on the injured legs and
post-operative outcomes and complications. These
outcomes have been shown in percentage and
frequency and mean values of various variables.
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Table – I: Demographic characteristics of the Patients (Number = 41)

Characteristics Number Percentage
Mean age (Years) 31.8
Motor cycle 17 40.47
Mode of Injury
Vehicle injury 10 23.8
Gunshot injury 5 11.9
Pedestrian 3 7.14
Fall of heavy objective 3 7.14
Farm injury 3 7.14
Proximal tibia 7 16.66
Site of Injury

Middle tibia 12 28.56

Distal tibia 17 40.47
Distal 2/3rd 2 4.76
Middle 2/3rd 4 9.52

Demographic characteristics
Middle 2/3rd 9.52
Mode of Injury Site of Injury

4
Distal 2/3rd 2 4.76
Distal tibia 17 40.47
Middle tibia 12 28.56
Proximal tibia 7 16.66
Farm injury 3 7.14
Fall of heavy objective 3 7.14
Pedestrian 3 7.14
Gunshot injury 5 11.9
Vehicle injury 10 23.8
Motor cycle 17 40.47
0 5 10 15 20 25 30 35 40 45
Percentage Number 2 Periode gleit. Mittelw. (Percentage)

Table – II: Types of fixator and pattern of flaps done (Number = 41)
Characteristics Number Percentage
of

AO fixator 15 35.71
N A fixator 12 28.57
Fixators

T clamp 13 30.95
Type

Illizrov Ext. Fixator 2 4.75

Proximal based lateral 4 9.52
Proximal based medial 3 7.14
Distal based lateral 17 40.47
Pattern of Flaps Done

Distal based medial 8 19

Cross leg flaps 2 4.17
Sural flap 2 4.17
Distal retrograde flap 4 9.52
Random pattern flap 2 4.76
Soleus muscle flap 2 4.76

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 IAJPS 2018, 05 (05), 4040-4045 Laiq et al ISSN 2349-7750

Types of fixator and pattern of flaps

Soleus muscle flap 2 4.76
2 4.76
Pattern of Flaps

Distal retrograde flap 4 9.52

2 4.17
Done

Cross leg flaps 2 4.17

8 19
Distal based lateral 17 40.47
37.14
Proximal based lateral 4 9.52
2 4.75
Fixators
Type of

T clamp 13 30.95
12 28.57
AO fixator 15 35.71
0 5 10 15 20 25 30 35 40 45
Percentage Number 2 Periode gleit. Mittelw. (Percentage)
Table – III: Post-operative complications and outcome (Number = 41)
Complications Number Percentage
Mean of hospital stay (Days) 30.6
Marginal Necrosis 6 14.28
Complications

Partial Necrosis 1 2.38

Complete Necrosis 2 4.76
Superficial Infection 3 7.14
Deep Infection 5 11.9
Good 33 78.57
Results

Fair 6 14.28
Final

Poor 3 4.76

Post-operative complications and outcome

90 78.57
80
70
60
50
40 33
30
20 14.28 11.9 14.28
10
6 1 2.38 2 4.76 3 7.14 5 6 3 4.76
0
Marginal Partial Complete Deep Good Fair Poor
Necrosis Necrosis Necrosis Superficial Infection
Infection
Complications Final Results
Number Percentage 2 Periode gleit. Mittelw. (Percentage)

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DISCUSSION:
Soft tissue defects coverage in (type 111 – B) in the
open tibial fractures is presently frequent intervention
because of the high trauma incidences in this
prominent setting [15]. Skilled orthopedic surgeons
are required for the management of these fractures
and related complications [5]. British plastic
surgeon’s association and British orthopedic
association has forced on the combined treatment by
plastic and orthopedic surgeons for the management
of the severe cases of the open tibial fractures;
whereas, a number of the healthcare facilities are
functioning without any plastic surgeons [16].
Availability of the plastic surgeons is an issue
because of the overburdened routine and less number
of the plastic surgeons. An orthopedic surgeon sound
in the practical and theory about the vascular
anatomy manages the soft tissue coverage procedure
expertly specially in these kind of injuries through
less damage, simple operation and in the non-
availability of the specific tools [1]. The reliability of
the fascio-cutaneous flaps is sure and another
associated advantage is their simplified execution
[17]. The utilization of the flaps can be made on the
distally across leg transverse or ipsilateral limb,
which depends on the size and site of leg defect [18].
An improved blood supply awareness and design of
the flaps makes it longer, safer and useful flap [19].
According to the Debabarma S. et al, survival rate
was observed as 76.5% in the application of the
fascio-cutaneous flaps and deep infection was
observed in 23.33% cases [20]. Naique SB is of the
view that fascio-cutaneous flaps were used in 35
patients in (type 111 – B) serial of the open tibial
fractures with 80% rate of the full acceptance, 8.57%
cases of minor tip necrosis and 11.42% cases were
observed with flap failure [16]. Various outcomes
have also been reported by various other authors
about the fascio-cutaneous flaps and success rates
[13, 21, 22].
We harvested two sural flaps over 1/3rd distal of leg.
Two cases were treated with cross-leg transverse
flaps with extensive defect in 2/3rd middle of tibia.
Two cases were of soleus muscle flap with an
extensive soft tissue loss in 2/3rd middle of leg which
was additional to the SSG and fascio-cutaneous flaps.
Development of six flaps was observed in the
marginal necrosis, one cross leg flap and one sural
flap also observed with the development of the
marginal necrosis. One heavy smoker case was also
noticed in this research. Without the application of
any other procedure proper and complete healing was
observed in all the cases. Although there were three
cases of poor outcomes of various necrosis at various
stages but with eh continued treatment of the
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Laiq et al ISSN 2349-7750
antibiotics and multiple debridement, covering of the
wound was performed with soleus muscle flap, distal
based lateral flap and SSG. Severe infection and
necrosis of the fascio-cutaneous flap was also seen
one of the poor cases, revised flaps treatment was
carried out in all these three cases.
Multiple dressings were carried out in the patients of
superficial infections. Severely infected wound was
observed in one case who reported after ten days of
being injured at his farm and during this lapse he was
under the treatment of a local bone setter, he was
treated with the discharging sinus after flap healing.
Gunshot cases were also observed as four cases were
registered having an infected non-union and multiple
piece of sequestrum. One case of the head injury was
kept under observation in the department of the
neurosurgery for number of days with a neglected
open tibial fracture. Severe infection and necrosis
was also developed in his flap. In the non-unions
cases illizrov external fixator was applied along with
sequestrum. Two other cases were treated with the
removal of the small stones of the sand from the sight
of the wound.
It is encouraging that our outcomes can be compared
to all the nationally held research studies on the same
topic including international and regional research
studies. The results also agree with the outcomes of
the Booplan PR, as he states about the failures
attribution to the infected wound state and nature of
the bed at arrival instead of the flap [23].
CONCLUSION:
Our research concludes that fascio-cutaneous flap is a
procedure which is safe, simple and cost effective
along with (type 111 – B) good acceptance of the
open tibial fractures. With the provision of the
restricted sources orthopedic surgeons with local
vessels awareness can be helpful in the overall
independent and composite improvement of the (type
111 – B) care of the open tibia fractures for the
timely and improved treatment in under-developed
nations.
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3. Tarkin IS. Siska PA, Zella BA. Soft tissue and
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North Amer 2010; 41(1): 19-126.
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